How Do Children Behave Regarding Their Birth Order in Dental Setting?

STATEMENT OF THE PROBLEM
Prediction of child cooperation level in dental setting is an important issue for a dentist to select the proper behavior management method. Many psychological studies have emphasized the effect of birth order on patient behavior and personality; however, only a few researches evaluated the effect of birth order on child's behavior in dental setting.


PURPOSE
This study was designed to evaluate the influence of children ordinal position on their behavior in dental setting.


MATERIALS AND METHOD
A total of 158 children with at least one primary mandibular molar needing class I restoration were selected. Children were classified based on the ordinal position; first, middle, or last child as well as single child. A blinded examiner recorded the pain perception of children during injection based on Visual Analogue Scale (VAS) and Sound, Eye and Movement (SEM) scale. To assess the child's anxiety, the questionnaire known as "Dental Subscale of the Children's Fear Survey Schedule" (CFSS-DS) was employed.


RESULTS
The results showed that single children were significantly less cooperative and more anxious than the other children (p<0.001). The middle children were significantly more cooperative in comparison with the other child's position (p< 0.001).


CONCLUSION
Single child may behave less cooperatively in dental setting. The order of child birth must also be considered in prediction of child's behavior for behavioral management.


Introduction
Many researches have been enrolled to evaluate the effect of different factors on children behavior. It is essential for a pediatric dentist to recognize child's mood, personality and subsequently the child's behavior during a dental procedure. Frankl et al. [1] (1962) classified children based on their mood and behavior in a dental visit. The behavioural rating scale offered by Frankl is described as definitely negative (when the child is completely uncooperative, crying, very difficult to make progress); negative (when the child is uncooperative, very reluctant to listen/respond to questions, some progress possible); positive (when the child is cooperative, somewhat reluctant/shy), and definitely positive (when the child is completely cooperative and even enjoys the experience). [1] The prediction of child behavior in a dental visit will help the dentist select a method to control behavior management. Many studies reported that birth order of children may influence their personality. [2] A review of birth order in the available published English literature recommends a relationship between different indices of cognitive ability, particularly verbal abilities. [3] Studies showed that birth-order had impacts on the intelligence [4] and personality. [5][6] Sulloway proposed a family dynamics model, concerning the birth order, claiming that it can influence the personality and behavior. [5][6] All model profiles, from the oldest to the youngest child, showed certain characteristics which were consistent with their birth order in the family system. The first-born children are the center of attention and care, [7] although susceptible to stress and uncertain in difficult circumstances. [8] They represent adult attitudes, such as seriousness, controlling, being organized and target-oriented.
The only child represents some of the personality traits of the firstborn, mainly the high achiever's attitude, although they have their own particular personality traits. The only child can present defensiveness, desire innovation, perfectionism, self-confidence, controlling, rational, and intellectual behaviors. [1,6] However, there are still controversies over this issue. [9][10][11][12] To the best of our knowledge, just one published study evaluated the effect of birth order on the children behavior in dental settings. [13] This study was designed to evaluate how the children's ordinal position influences their behavior in dental measurements.

Materials and Method
The present study was a randomized triple-blinded cross-sectional study. The subjects consisted of 158 healthy (ASA 1) 5-7 years old children referring to dental clinic in downtown Shiraz, Iran. All participants had at least one primary mandibular molar which needed class (I) restoration. The inclusion criteria were negative history of either any previous dental treatment or previous unpleasant medical experience.
The consent forms were granted by the parents after receiving a complete explanation of the study proce- The anesthetic injection procedure was carried out by an academic pediatric dentist. A blind assessor, who was unaware of child's position in the family, asked the patients to rate their pain on visual analogue scale (VAS) diagram after injection. The assessor also objectively recorded the sound, eye, and movement (SEM) during the injections (Table 1). Total scores for SEM ranged from 0 to 9 based on 0-3 score for each parameter. For a robust assessment of the child's anxiety, two assessment methods; behavioral and self-report; were employed.
Using VAS assessment method (  . This scaling is related to different characteristics of dental therapy such as invasive dental treatments (injections and drilling) and also to more general medical procedures. Total scores consequently would range from 15 to 75 and a score of 38 or more would be associated with clinical dental fear. [15] During the trans-cultural adaptation of the CFSS-DS, only slight cultural adaptations were necessary. In any case, one examiner was in attendance when children were carrying out the measures. The items on the paper were read out loud and explained. The validity and reliability of the translated trial were confirmed. [17] Result The present study revealed that 36 children (%23) were only child and 122 had siblings (%77), 30 were firstborn (%19), 46 were middle (%29), and 46 were lastborn (%29).
The results of this study showed that the mean difference of VAS, SEM scales, and anxiety were statistically significant among the children based on birth order (p< 0.001) (Table 1a and 1b).  The results revealed that single children were significantly less cooperative and more anxious than the other children (p< 0.001) (Table 1c).

Discussion
The study showed that single children exhibit more problem and anxiety in dental procedures compared to other children. Single-born children are at the core centre of attention and care. Even though they adopt adult characteristics, they are vulnerable to stressful situations and uncertain in difficult positions. Dental practice is recognized as one of these stressful situations that children may confront during their life. [13] A study enrolled by Aminabadi et al. [13]  Although these contradictory findings can be explained by differences in the study designs, methods of data collection, and specific factors evaluated, biological factors may also play an important role in child nature.
It was shown that the effects of biological birth-order, resulting mainly from intrauterine influences on personality, may in fact explain the inconsistencies of personality between siblings. Whether as mostly psychological, biological, or a mixture, birth order appears to be diffidently linked to the personality development. [29] Birth-order influences should be regarded in combination with other factors such as gender, age dissimilarities between siblings, socioeconomic families, family environment, family morals, and culture. [30] Conclusion The birth order of children may affect their behavior in dental measurements just as it influences their personality. Single children exhibit more problem and anxiety in dental procedures compared with other children.